Functioning Federations

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Primary Care Federations are now accepted as the new form of collaboration between practices. They organise in a range of relationships from alliances, partnerships, networks, to joint ventures (BMA 2018), and have a number of roles, but their primary purpose is to add value to member practices, and generate collaborative quality delivery of primary care services. They do this as member organisations.

Interestingly much of the guidance for Federations is on the structure, the legal and financial frameworks, the communications and the ideas into action (NHS England 2016); but there is very little on how Federations organise.

In my view they have two main choices in terms of how they organise the relationships  between members, that have very different implications in terms of decision-making, governance and ability to be innovative.

  1. They work as a Club – Members pay fees and they receive services. The executive team, based on intelligence from the members, decides the services. If members don’t find the services useful they can decide to leave the club. Being a member in a club comes with clear boundaries (who can join) and sanctions (how members behave). These are really membership service organisations.
  2. They work as a Network – Using a clear shared purpose as its guide (usually about better primary care for the local population), Federations as Networks work collaboratively with members to collectively generate solutions to member problems, to advocate on behalf of members, to filter intelligence (there is a lot of advise being developed for primary care) to inform members, and to commission services on behalf of members. This is a peer-based relationship in service to members, bringing the diversity of membership into creative conversations and problem solving.

Networks are innovative forms that enable members to adapt, enabling the best of their members’ assets and resources for a collective and individual member benefit (Malby and Anderson Wallace 2016). They are democratic forms which, when well lead, can secure a future focused approach to collaboration.

Clubs are more akin to hierarchies with intelligence, decision-making, and governance residing in a central team. Here delegated authority can lead to a fixed approach, costly overheads and an inability to adapt and innovate.

The Advantages and Disadvantages of the Club Approach for Federations

The advantage is that these Federations can quickly mobilise to secure funding streams.

The disadvantage is that these Federations become increasingly hierarchical as they project manage services. The services that they provide can in fact disable the local primary care system by:

  • Providing sticking plaster solutions rather than addressing the fundamental redesign that primary care needs to be fit for purpose. Often Federations have a short term view of securing enough access and capacity. Our work through the London Primary Care Quality Academy is finding that the practices we work with are usually convinced at the outset that they cannot cope with rising demand. Using data generated by the practices we find that (a) demand isn’t always rising but the complexity of the demand is changing and (b) if they change the way they organise, particularly their ‘sorting’, they do have the capacity, and can even generate more capacity, reducing their DNAs, and offering more appointments. Practices need support to understand and manage their demand and then support to work with communities to reduce demand. However Federations in the Club mode don’t necessarily have the collective capacity to work upstream, they tend to generate a dependency culture that ‘fixes’ their member’s problems in ways that can stack up more problems in the future. This perpetuates an individual member approach rather than bringing members together to collaborate. It also means that members become passive recipients making it harder and harder for the Federation to function, as it gets nothing back from the members apart from their membership funds.
  • Becoming caught up in project management – the bureaucracy of managing the reporting and project demands of external programme funding. Often these types of organisations end up using member’s fees to subsidise the costs of the projects they have taken on with external funding. Often Federations underestimate the time and cost of administering these new programmes and services. They end up taking on more staff and then have the pressure to keep on securing funding to pay ongoing salaries. It becomes a self-perpetuating circle that looses track of members real needs.

We see more of this approach in Federations as it has a more traditional management feel to it, and is a model that is familiar to many leaders. It is in effect a hierarchy.

The Advantages and Disadvantages of the Network Approach for Federations

The biggest disadvantage is that many federation leaders are unfamiliar with what it takes to lead a network.  In networks leaders are facilitators and enablers rather than experts and fixers, and this may not be a set of skills that Federation leaders are familiar with. Networks also take time to get going, their effectiveness is predicated on building momentum amongst members not on behalf of members. It requires members to put some effort in at the outset to collectively develop their Federation. Where practices have become passive players in a system controlled by CCGs, and where change is incentivised rather than co-created, it does require a change in culture.

The advantage of a network approach is that it brings all the members into the work of the Federation, so that everyone contributes and everyone benefits. It generates accountability and brings practices closer together. It helps collaboration and generates sustainability. Everyone contributes and everyone gains. Here the members hold the network leadership team (the executive) to account , and also hold each other to account as peers. Networks are the best form for spreading innovation and knowledge. They are excellent at filtering evidence and intelligence, and in ensuring members voice is amplified. They build community and secure impact across all members. It is possible to deliver services through a network model – the advantages being that the whole membership takes responsibility and co-designs the service. In terms of contracting services on behalf of members, the network again can do this as a service function, with a membership sub-group taking responsibility, or the members delegate authority to a core team.

What this means for Federations

These very different forms (Club and Network) determine:

  • What counts as added value
  • What collaboration looks like
  • The responsibility and accountability of the Federation central team and of members.

Here is an example of the work of one Federation: Federated 4 Health

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On the whole most Federations are doing these types of activities and I have laid out which approach (Club or Network) best suits the work, and the relative impact.

All of the work of a Federation can be done through either model, but in my view the Network model is more effective.

Task

Club

Network

Spreading clinical best practice This tends to be an information giving approach with little filtering. Impact: Poor A learning approach with the network generating a sub group to filter evidence and share with members. Impact: Good
Development of quality and safety systems There is no reason for a member to take part in this unless it is a mandated part of membership.  Impact: Poor A learning approach – with self-selected members taking a lead and working with all members to secure the development of quality and safety systems across all members for the benefit of the population. Impact: Good
Consistent services Hard to secure in a passive membership without incentives.  Impact: Poor A learning and development approach to securing consistency through peer support and identification with the collective benefit. Impact: Good
Sharing and avoiding duplication of policy and paperwork Mediated through the central team. Impact: Good Can be mediated by the leadership team or delegated to a sub team. Impact: Good
Sharing of staff expertise Mediated through the central team. Impact: OK Directly between members. Impact: Good
Purchasing together (from consumables, to training, to legal advice) Managed by the central team. Can be poorly informed.  Impact: – depends on local relationships Specification agreed by whole membership as a result of collaborative service review. Managed by sub-team of leadership team. Impact: Good
Tendering Managed by the central team. Can be poorly informed. Can mean some practices are favoured over others. Impact: – depends on local relationships. Agreed by the membership with collaborative agreements about securing equal distribution. Impact: Good
Developing and using business intelligence (BI) Depends on whether there is a BI function in the central team Depends on whether there is a BI function in the leadership team or amongst members.
Premises and infrastructure Back office systems Brokered by central team. Impact: Good Emerges from collaborative relationships. Impact: Good
Education and training Commissioned by the central team based on member identified need. Impact: depends on uptake and relevance. Commissioned by the network via the administrative team, Quality Assurance from a sub-group, and learning needs are identified collaboratively. Impact: more likely to generate uptake.
Collaborative care models Brokered by central team. Impact: depends on how engaged practices are. Emerges from collaborative relationships. Impact: Good – real buy in.
Working with secondary care Brokered by central team.  Impact: depends on vision, relationships with secondary care, and ability to secure compliance from members. Network sub group working on behalf of members, bringing decisions back to members. Time spent understanding the issues and developing relationships across multiple members with secondary care. Impact: can be good where there is a collective response.
Better engagement with the local population Brokered through an engagement model. Impact: partial Coproduced with citizens as partners. Impact: mutual assets that secure new approaches to reducing demand.

In the literature on Federations the network form is often associated with smaller groups of practices (Imison et al 2018) but this fails to understand the different types of networks. Delivery networks are often larger groups of organisations, and have a delegated governance model.

Federations, to ensure they have the capacity to adapt and innovate at the front line of the NHS need to develop network leadership capabilities and design collaborative network relationships between and across members to realize the assets of the whole primary care system.

The Source 4 Networks diagnostic tools are a good starting point for securing member-wide agreement on vision, direction and participation.

References

BMA (2018) GP Networks and Federations. Updated February 2018. BMA Online (accessed 27 March 2018)

Imison, C., Williams, S., Smith, J., Dingwall, C. (2013) Toolkit to Support the Development of Primary Care Federations. Kings Fund, Nuffield Trust, Hempsons.

Malby, B., & Anderson-Wallace, M. (2016) Networks in Healthcare. Managing Complex Relationships. Emerald.

NHS England South (South West). (2016) Supporting Sustainable General Practice. A guide to networks and federations for general practice. (Accessed 27 March 2018)